1. Complications of the Third Stage of Labour www.freelivedoctor.com

2. Complications of the Third Stage of Labour Include: * Postpartum haemorrhage. * Retained placenta. * Inversion of the uterus. * Obstetric shock (collapse). www.freelivedoctor.com

3. POSTPARTUM HAEMORRHAGE www.freelivedoctor.com

4. POSTPARTUM HAEMORRHAGE Definition:It is excessive blood loss, from the genital tract after delivery of the foetus exceeding 500 ml or affecting the general condition of the patient. Types: a.Primary postpartum haemorrhage:> Bleeding occurs during the 3rd stage or within 24 hours after childbirth. It is more common. b. Secondary postpartum haemorrhage:> Bleeding occurs after the first 24 hours until 6 weeks (the end of puerperium). www.freelivedoctor.com

5. PRIMARY POSTPARTUM HAEMORRHAGE Aetiology:a.Placental site haemorrhage * Atony of the uterus: > is the cause of primary postpartum haemorrhage in more than 90% of cases. >The factors that predispose to uterine atony are: Antepartumhaemorrhage. Severe anaemia. Overdistension of the uterus. Uterine myomas. Prolonged labour exhausting the uterus. Prolonged anaesthesia and analgesia. Full bladder or rectum. Idiopathic. * Retained placenta. * Disseminated intravascular coagulation (DIC). www.freelivedoctor.com

6. PRIMARY POSTPARTUM HAEMORRHAGE Aetiology:Traumatichaemorrhage Rupture uterus, cervical, vaginal, vulval or perineal lacerations. www.freelivedoctor.com

7. Diagnosis General examination * The general condition of the patient is corresponding to the amount of blood loss. * In excessive blood loss, manifestations of shock appear as hypotension, rapid pulse, cold sweaty skin, pallor, restlessness, air hunger and syncope. www.freelivedoctor.com

8. Diagnosis General examination * The general condition of the patient is corresponding to the amount of blood loss. * In excessive blood loss, manifestations of shock appear as hypotension, rapid pulse, cold sweaty skin, pallor, restlessness, air hunger and syncope. www.freelivedoctor.com

9. Diagnosis Abdominal examination * In atonic postpartum haemorrhage: The uterus is larger than expected, soft and squeezing it leads to gush of clotted blood per vagina. * In traumatic postpartum haemorrhage: The uterus is contracted. Combination of the 2 causes may be present. www.freelivedoctor.com

10. Diagnosis Vaginal examination >In atony: Bleeding is usually started few minutes after delivery of the foetus. * It is dark red in colour. * The placenta may be not delivered. >In trauma: Bleeding starts immediately after delivery of the foetus. * It is bright red in colour. * Lacerations can be detected by local examination. www.freelivedoctor.com

11. Management Prevention Treatment www.freelivedoctor.com

13. Previous postpartum haemorrhage.

14. Polyhydramnios and multiple pregnancy.

15. Grand multipara.www.freelivedoctor.com

16. Management Prevention: During labour: a. Proper use of analgesia and anaesthesia. b. Avoid prolonged labour by proper oxytocin which should be extended to the end of the 3rd stage if used. c. Avoid lacerations by: > Proper management of the 2nd stage. >Follow the instructions for instrumental delivery (see later). d. Routine use of ecbolics in the 3rd stage of labour. e. Routine examination of the placenta and membranes for completeness. www.freelivedoctor.com

17. Management Prevention: *Postpartum: > Exploration of the birth canal after difficult or instrumental delivery as well as precipitate labour. > Careful observation in the fourth stage of labour (1-2 hours postpartum). www.freelivedoctor.com

18. Treatment (I) Restoration of blood volume: Urgent cross-matched blood transfusion with the other antishock measures is given. Colloids and/or crystalloids therapy can be started till availability of the blood. www.freelivedoctor.com

19. Treatment (II) Arrest of bleeding: Placental site bleeding: Before delivery of the placenta: The placenta should be delivered by; * Ergometrine and massage with gentle cord traction if failed, * Brandt -Andrews manoeuvre if failed do, * Crédé’s method if failed do, * manual separation of the placenta www.freelivedoctor.com

20. Treatment (b) After delivery of the placenta: The following steps are done in succession if each previous one fails to arrest bleeding: www.freelivedoctor.com

22. Massage of the uterus and ecbolics as:> Oxytocin drip: 10-20 units in 500 ml glucose 5% or normal saline. It may be given (5 units) directly intramyometrial in case of C.S. > Ergometrine (Methergin): 1-2 ampoules (0.25-0.50 mg) IV or IM. > Syntometrine 0.5 mg IV if available. www.freelivedoctor.com

23. Treatment Prostaglandins (PGs): > 0.25 mg methyl PG F2a IM (Prostin methyl ester) or >1 mg PG F2a intramyometrial in case of C.S. or >20 mg PG E2 (Prostin E2) rectal suppositories every 4-6 hours. www.freelivedoctor.com

24. Treatment Bimanual compression of the uterus: > Under general anaesthesia, the uterus is firmly compressed for 5-30 minutes between the closed fist of the right hand in the anterior vaginal fornix and the left hand abdominally behind the body of the uterus. > The compression is maintained until the uterus is firmly contracted. During this period, blood transfusion, oxytocin and ergometrine are given. www.freelivedoctor.com

25. Treatment Bilateral uterine artery ligation: > The surgeon stands on the left side of the patient to control the procedure more. >The uterus is grasped by the assistant and elevated upwards and to the opposite side of the uterine artery which will be ligated to expose the vessels coarse through the broad ligament. > A large atraumatic needle with no. 1 chromic cutgut, O-vicryl or O-Dexon is passed through and into the myometrium from anterior to posterior 2-3 cm medial to the uterine vessels. www.freelivedoctor.com

26. Treatment > The needle is brought forward through avascular area in the broad ligament lateral to the uterine artery and vein. The suture is tied anteriorly. >In case of caesarean section, the sutures are placed 2-3 cm below the level of uterine incision under the reflected peritoneal flap which should be displaced downwards with the bladder to avoid ligation of the ureters. www.freelivedoctor.com

28. Uterine artery ligation is haemostatic by reducing the pulse pressure to the uterus as 90% of its blood supply is from the uterine vessels.

29. Collateral circulation and recanalization of the uterine vessels will be established within 6-8 weeks.

30. It has a success rate of 95%.www.freelivedoctor.com

31. Treatment Bilateral ligation of ovarian supply to the uterus: > If bleeding continues after uterine arteries ligation a second mass bilateral ligation is done high up in the site of anastomosis between the uterine and ovarian arteries near the cornua of the uterus. www.freelivedoctor.com

32. Treatment Bilateral internal iliac artery ligation: >The posterior peritoneum lateral to the infundibulo-pelvic vessels is opened. >The ureter is indentified on the posterior leaf of the broad ligament and retracted medially. >The bifurcation of the common iliac artery at the level of the sacroiliac joint is identified and the internal iliac vessels are identified and ligated with no.1 non-absorbable silk suture. >Most surgeons do not close the peritoneum over this area. > It has a success rate of 40%. www.freelivedoctor.com

33. Treatment Hysterectomy: Subtotal hysterectomy which is more rapid and easy than total hysterectomy is done. www.freelivedoctor.com

34. Treatment Other less commonly used methods to arrest bleeding: 1. Uterine packing: >Under general anaesthesia. > Foley's catheter is applied. > Packing the whole uterus, cervix and vagina with a sterile gauze starting from the fundus downwards in tightly packed layers where each roll of gauze is tied to the next. > It is removed after 6-12 hours. www.freelivedoctor.com

35. Treatment 2.Foley’s balloon: > A large Foley’s catheter balloon is inflated to control haemorrhage from lower uterine segment which may result from placenta praevia or cervical pregnancy. www.freelivedoctor.com

36. Treatment 3.Aortic compression: The aorta is compressed manually against the lumbar spines through the abdomen providing temporary control of heavy bleeding till preparing for surgical interference. www.freelivedoctor.com

37. Treatment 4. Radiographic trans-arterial immobilisation: >By a trained radiologist selective immobilisation of the pelvic vessels may be done using the angiographic technique. www.freelivedoctor.com

38. Complications Maternal death in 10% of postpartum haemorrhages. Acute renal failure. Embolism. Sheehan’s syndrome. Sepsis. Anaemia. Failure of lactation. www.freelivedoctor.com

39. SECONDARY POSTPARTUM HAEMORRHAGE Aetiology: a. Retained parts: of the placenta, membranes, blood clot or formation of a placental polyp. b. Infection: > separation of infected retained parts. >infected C.S. wound >infected genital tract lacerations. > infected placental site. www.freelivedoctor.com

40. SECONDARY POSTPARTUM HAEMORRHAGE Aetiology: Fibroid polyp: necrosis and sloughing of its tip. Subinvolution of the uterus. Local gynaecological lesions: e.g. cervical ectopy or carcinoma. Choriocarcinoma. Puerperal inversion of the uterus. Oestrogen withdrawal bleeding: if oestrogen was given for supression of lactation. www.freelivedoctor.com